The Australian Transport Safety Bureau (ATSB) is Australia's national transport safety investigator. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport. The ATSB is Australia's prime agency for the independent investigation of civil aviation, rail and maritime accidents, incidents and safety deficiencies.

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Pilot distraction

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The ATSB's investigation
AO-2011-151 into an incident on 8 October 2011 has once again
highlighted the risks of pilots becoming distracted during the
critical stages of flight preparation. It also emphasises the
importance of good flight crew communication to ensure a shared
understanding of an aircraft's systems status.

The incident occurred when the flight crew of an Airbus
A380-800, registered VH-OQE, was preparing for departure from Los
Angeles International Airport. Before takeoff, the captain changed
the departure runway that was entered in the aircraft's flight
management system. The procedure for completing that task was not
followed exactly, resulting in the take-off speeds not being
displayed on the flight instruments.

During the take-off roll, the flight crew, becoming aware that
the take-off speeds were not displayed, called out the speeds from
their notes instead, and proceeded with the takeoff. At all times
during the takeoff, the crew were aware of how fast they were
going. However, the take-off speeds that are normally displayed on
the airspeed indicator were not visible for this takeoff.

The ATSB found that the captain had been distracted from
updating the runway change in the aircraft's navigation systems
before the aircraft taxied for the runway. Twice, before takeoff,
the aircraft's systems displayed a message to check take-off data.
The first officer cleared the first message on the understanding
that the take-off data would be checked and in the second instance,
believing that it had been checked. There were no other warnings to
alert the crew that they were commencing the takeoff without the
take-off speeds in the aircraft's navigation systems.

Following this incident the aircraft manufacturer has updated
the aircraft's warning systems as part of a planned upgrade
program. This upgrade will issue a warning if takeoff is commenced
without the take-off speeds having been entered into the aircraft's
systems. Qantas advised that their standard operating procedures
have been updated to avoid any misinterpretation of the required
actions in the case of a runway change.